Wickford Auto Club Targa entry form

All entries are provisional until payment is received. The quickest way to pay and secure your place is to pay by PayPal or Credit/Debit Card. BACS payment will take longer to be processed as received.

Second Driver

DOUBLE DRIVING

If you are double driving please indicate double driving below, and then fill in the form for the first driver/passenger combination. After clicking submit, you will be directed to the second driver form where you can enter the second driver/passenger combination.

Double driving
*

Yes No

Second Entry

Yes No

Drivers Name
*

Driver's Address #
*

Driver's E-mail
*

Drivers Mobile #
*

Drivers Home Phone #

Driver's Club
*

MA Masters with engine capacity 1400cc or lessMB Masters with engine capacity over 1400ccEA Experts with engine capacity 1400cc of lessEB Experts with engine capacity over 1400ccNA Novices with engine capacity 1400cc or lessNB Novices with engine capacity over 1400cc

Forced Induction counts as 1.5 times the engine capacity

Driver Class
*

MA MB EA EB NA NB

Driver's Emergency contact name, address & telephone details in the event of an emergency (Put "As above" if the same as driver)

Driver's Emergency contact
*

Navigator
*

Navigator Address #
*

Navigator E-mail
*

Navigator Mobile #
*

Navigator Home Phone #

Navigator Club
*

Passenger's Emergency contact name, address & telephone details in the event of an emergency (Put "As above" if the same as passenger)

Navigator Emergency Contact
*

Car Make
*

Model
*

CC
*

Registration No
*

Historic Award

Yes No

1. I have been given an opportunity to read the General Regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit and competent to take part in the event. I understand that motorsport is dangerous and accidents causing death, injury, disability and property damage can and do happen. I understand that these risks may give rise to my suffering personal injury or other loss and I acknowledge and accept these risks. 2 . To the best of my belief the driver(s) possess(es) the standard of competence necessary for an event of the type to which this entry relates and that the vehicle entered is suitable and roadworthy for the event having regard to the course and the speeds which will be reached. 3 . The use of the vehicle hereby entered is covered by insurance as required by the law which is valid for such part of this event as shall take place on roads as defined by the law. 4 . I understand that should I at the time of this event be suffering from any disability whether permanent or temporary which is likely to affect prejudicially my normal control of the vehicle, I may not take part unless I have declared such disability to the ASN which has, following such declaration, issued a licence which permits me to do so. 5 . Any application form for a Licence which was signed by a person under the age of 18 years was countersigned by that person’s parent/legal guardian/guarantor, whose full names and addresses have bee n given. 6 . If I am the Parent/Guardian/Guarantor of the driver I understand that I shall have the right to be present during any procedure being carried out under the Supplementary Regulations issued for this event and the General Regulations of the MSA. As the Parent/Guardian/Guarantor I confirm that I have acquainted myself with the MSA General Regulations, agree to pay any appropriate charges and fees pursuant to those Regulations (to include any appendices thereto) and hereby agree to be bound by those Regulations and submit myself without reserve to the consequences resulting from those Regulations (and any subsequent alteration thereof). Further, I agree to pay as liquidated damages any fines imposed upon me up to the maximum set out in Part 3, Appendix 1. Note: Where the Parent/Guardian/Guarantor is not present there must be a representative who must produce a written and signed authorisation to so act from the Parent/Guardian/Guarantor as appropriate. 7 . I hereby agree to abide by the MSA Child Protection Policy and Guidelines and the National Sporting Code of Conduct. 8. I undertake that at the time of the event to which this entry relates I shall have passed or am exempt from an ASN specified medical examination within the specified period. (H10.1.6) 9 . I have read and fully understood the Procedure for Control of Drugs and Alcohol as contained in the MSA Yearbook Regulations H39, D35.1, G15.1.4 and have also fully familiarised myself with the information on the web sites referred to ( www.ukad.org.uk and www.wada-ama.org ) in particular the UK Anti- Doping Rules which have been adopted by the MSA (as amended). Further, if I am counter-signing as the Parent or Guardian of a minor then in addition to the deemed consent to the testing of that minor (Art 5.6.2) I hereby confirm that I give such consent for the minor concerned to be so tested. Indemnity : In consideration of the acceptance of this entry I agree that neither any one of or any combination of the MSA and its associated clubs, the organisers, the land owners or other occupiers, the promoters and their respective officers, servants, representatives and agents (the "Parties") shall have any liability for loss or damage which may be sustained or incurred by me as a result of participation in this event. Nothing in this clause is intended to or shall be deemed to exclude or limit liability for death or personal injury. To the fullest extent permitted by law I agree to indemnify and hold harmless each of the Parties in respect of any loss or damage whatsoever and howsoever arising from my participation in this event. I agree to WSMC Ltd WAC Ltd & AMSC Ltd retaining my details and contacting me regarding other motorsport events that the club is involved with. WSMC, WAC and AMSC will not under any circumstances pass on your details to any other person or organisation.